Adult Evaluation & Review Services (AERS) Referral & Intake Form

Adult Evaluation & Review Services (AERS) Referral & Intake Form
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*

FemaleMale
Phone Number (client or primary contact)*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Social Security Number is not required to make a referral, but will need to be provided prior to the AERS assessment.
Race

WhiteBlack / African AmericanHaitianHispanicAsianOther
If you answered "other" for the question above regarding race, please provide the client's race(s).
Client's primary language

EnglishSpanishHaitian CreoleUrduOther or Unknown
Marital Status

Single, Never MarriedMarriedSeparatedWidowedDivorcedOther
Does the client live alone?*

YesNoUnknown
If the client does not live alone, please list household members and their relationship to client.
The program requires an assessment before services can be provided. Please provide the name, phone number, and email address of the best person to contact to schedule the assessment.*
Does the client have a legally appointed Power of Attorney or guardian?

YesNo
If you answered "yes" that the client has a legally appointed Power of Attorney or guardian, please provide their name and phone number.

First NameLast Name
Legally appointed Power of Attorney or guardian phone number (if applicable)
Please enter a valid phone number.
Primary Care Provider

First NameLast Name
Primary Care Provider Phone Number
Please enter a valid phone number.
Has the client had a recent hospitalization or rehabilitation center stay?

YesNo
What type of insurance does the client have? Check all that apply.

MedicareMedicaidPrivate InsuranceUninsuredUnknown insurance status
Is the client a veteran?

YesNoUnknown
Referral Information
The Maryland Department of Health provides various Long Term Services and Supports for individuals over 65, individuals with physical disabilities, individuals with intellectual disabilities, chronically ill children, and individuals eligible for both Medicaid and Medicare (“dual eligibles”). Medicaid covers certain services available to these participants based on medical necessity and technical and financial eligibility.

Long Term Services and Supports are provided in home and community-based settings, as well as in institutions.

To learn more about the programs available, visit the Maryland Department of Health website.
Referral Source

SelfFamily MemberFriendCommunity AgencyOther
If the referral is made by anyone other than the prospective client (self), please provide the name and phone number of the person making the referral.

First NameLast Name
Referring Individual Phone Number
Please enter a valid phone number.
Please provide the reason for the AERS referral. Include information about primary medical issues, what type of assistance or support the person needs, information about current services and supports already in place (such as home health, physical therapy, occupational therapy, counseling, etc.).
Please note that if the prospective client does not have Medical Assistance, we can consider them for SSTA/Senior Care through the Department of Social Services. Senior Care can provide case management and other additional supports based on availability and eligibility. For example, it is possible to access incontinence supplies, an alarm guard, etc., as well as possibly an aide to assist with some personal care and tasks at home. There is a wait list and while AERS will provide the evaluation to refer to Senior Care, the client must meet age, functional needs (determined through evaluation), and income guidelines to be eligible. The approximate monthly maximum individual income is $3,121, with assets not above $11,000 or for a couple, $4,081 a month, with assets not above $14,000.
Should the client not meet the criteria for AERS, are you interested in an evaluation for referral to Senior Care?

YesNo
Is the client at least 65 years old?

YesNo
Please provide any additional information or comments you think would be helpful to AERS staff as we review this referral.
Should be Empty:

Adult Evaluation & Review Services (AERS) Referral & Intake Form

Referral Information